Ali Z Nomani1, Joseph Kamtchum Tatuene2, Jeremy L Rempel2, Thomas Jeerakathil2, Ian R Winship2, Khurshid A Khan2, Brian H Buck2, Ashfaq Shuaib2, Glen C Jickling2. 1. From the Division of Neurology, Department of Medicine (A.Z.N., T.J., I.W., K.A.K., B.H.B., A.S., G.C.J.), Neuroscience and Mental Health Institute, Department of Medicine and Dentistry (J.K.T.), Department of Radiology (J.L.R.), and Department of Psychiatry (I.W.), University of Alberta, Edmonton; and Red Deer Regional Hospital (A.Z.N.), Canada. anomani@ualberta.ca. 2. From the Division of Neurology, Department of Medicine (A.Z.N., T.J., I.W., K.A.K., B.H.B., A.S., G.C.J.), Neuroscience and Mental Health Institute, Department of Medicine and Dentistry (J.K.T.), Department of Radiology (J.L.R.), and Department of Psychiatry (I.W.), University of Alberta, Edmonton; and Red Deer Regional Hospital (A.Z.N.), Canada.
Abstract
BACKGROUND AND OBJECTIVES: The rate of infarct core progression in patients with acute ischemic stroke is variable and affects outcome of reperfusion therapy. We evaluated the hypoperfusion index (HI) to estimate the initial rate of core progression in patients with medium vessel occlusion (MeVO) compared to large vessel occlusion (LVO) stroke and within a larger time frame since stroke onset. METHODS: Core progression was assessed in 106 patients with acute stroke and CT perfusion. Using reperfusion trial core time criteria, fast progressors had core >70 mL within 6 hours of stroke onset and slow progressors had core ≤70 mL, mismatch ≥15 mL, and mismatch to core ratio ≥1.8 within 6 to 24 hours. The relationship between HI and infarct core progression (core/time) was examined using receiver operating characteristics to determine optimal HI cutoff. The HI cutoff was then tested in the overall cohort, compared between MeVO and LVO, and evaluated in patients up to 24 hours from stroke onset to differentiate fast from slow rate of core progression. HI threshold was assessed in a second independent cohort of 110 patients with acute ischemic stroke. RESULTS: In 106 patients with acute stroke, 6.6% were fast progressors, 27.4% were slow progressors, and 66% were not classified as fast or slow progressor by reperfusion trial core time criteria. HI >0.5 was associated with fast progression and able to distinguish fast from slow progressors (area under the curve [AUC] 0.94; 95% confidence interval [CI] 0.80-0.99). In MeVO (n = 26) HI >0.5 had a core progression of 0.30 mL/min compared to 0.03 mL/min for HI ≤0.5 (p < 0.001). In LVO (n = 80), HI >0.5 had a core progression of 0.26 mL/min compared to 0.02 mL/min for HI ≤0.5 (p < 0.001). In patients not classified as fast or slow progressor by reperfusion trial criteria, those with HI >0.5 had progression rate of 0.21 mL/min compared to 0.03 mL/min for those with HI ≤0.5 (p < 0.001). Validation in a second cohort of patients with acute ischemic stroke (n = 110; MeVO = 42, LVO = 68) yielded similar results for HI >0.5 to distinguish fast and slow core progression with an AUC of 0.84 (95% CI 0.72-0.97). DISCUSSION: HI can differentiate fast from slow core progression in MeVO and LVO within the first 24 hours of acute ischemic stroke. Consideration of core progression rate at time of stroke evaluation may have implications in the selection of patients with MeVO and LVO stroke for reperfusion therapy that warrant further study.
BACKGROUND AND OBJECTIVES: The rate of infarct core progression in patients with acute ischemic stroke is variable and affects outcome of reperfusion therapy. We evaluated the hypoperfusion index (HI) to estimate the initial rate of core progression in patients with medium vessel occlusion (MeVO) compared to large vessel occlusion (LVO) stroke and within a larger time frame since stroke onset. METHODS: Core progression was assessed in 106 patients with acute stroke and CT perfusion. Using reperfusion trial core time criteria, fast progressors had core >70 mL within 6 hours of stroke onset and slow progressors had core ≤70 mL, mismatch ≥15 mL, and mismatch to core ratio ≥1.8 within 6 to 24 hours. The relationship between HI and infarct core progression (core/time) was examined using receiver operating characteristics to determine optimal HI cutoff. The HI cutoff was then tested in the overall cohort, compared between MeVO and LVO, and evaluated in patients up to 24 hours from stroke onset to differentiate fast from slow rate of core progression. HI threshold was assessed in a second independent cohort of 110 patients with acute ischemic stroke. RESULTS: In 106 patients with acute stroke, 6.6% were fast progressors, 27.4% were slow progressors, and 66% were not classified as fast or slow progressor by reperfusion trial core time criteria. HI >0.5 was associated with fast progression and able to distinguish fast from slow progressors (area under the curve [AUC] 0.94; 95% confidence interval [CI] 0.80-0.99). In MeVO (n = 26) HI >0.5 had a core progression of 0.30 mL/min compared to 0.03 mL/min for HI ≤0.5 (p < 0.001). In LVO (n = 80), HI >0.5 had a core progression of 0.26 mL/min compared to 0.02 mL/min for HI ≤0.5 (p < 0.001). In patients not classified as fast or slow progressor by reperfusion trial criteria, those with HI >0.5 had progression rate of 0.21 mL/min compared to 0.03 mL/min for those with HI ≤0.5 (p < 0.001). Validation in a second cohort of patients with acute ischemic stroke (n = 110; MeVO = 42, LVO = 68) yielded similar results for HI >0.5 to distinguish fast and slow core progression with an AUC of 0.84 (95% CI 0.72-0.97). DISCUSSION: HI can differentiate fast from slow core progression in MeVO and LVO within the first 24 hours of acute ischemic stroke. Consideration of core progression rate at time of stroke evaluation may have implications in the selection of patients with MeVO and LVO stroke for reperfusion therapy that warrant further study.
Authors: Christoph J Griessenauer; Caroline Medin; Julian Maingard; Ronil V Chandra; Wyatt Ng; Duncan Mark Brooks; Hamed Asadi; Monika Killer-Oberpfalzer; Clemens M Schirmer; Justin M Moore; Christopher S Ogilvy; Ajith J Thomas; Kevin Phan Journal: World Neurosurg Date: 2017-11-23 Impact factor: 2.104
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Authors: Blanca Fuentes; María Alonso de Leciñana; Alvaro Ximénez-Carrillo; Patricia Martínez-Sánchez; Antonio Cruz-Culebras; Gustavo Zapata-Wainberg; Gerardo Ruiz-Ares; Remedios Frutos; Eduardo Fandiño; Jose L Caniego; Andrés Fernández-Prieto; Jose C Méndez; Eduardo Bárcena; Begoña Marín; Andrés García-Pastor; Fernando Díaz-Otero; Antonio Gil-Núñez; Jaime Masjuán; Jose Vivancos; Exuperio Díez-Tejedor Journal: Stroke Date: 2015-06-23 Impact factor: 7.914